The Journal of the American College of Radiology urges women to begin seeking mammograms every year beginning at age 40. The suggestion is "at odds with controversial advice by the US Preventive Services Task Force that women put off mammograms until age 50 and even then just get them every two years, in most cases." A professor of radiology at Harvard, charged that the USPTF "didn't pay enough attention to the results of studies
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Deepen your understanding of "medical malpractice"... www.MedMalBook.com
For more health info and links visit the author's web site www.hookman.com
Showing posts with label mammogram. Show all posts
Showing posts with label mammogram. Show all posts
Monday, April 5, 2010
Wednesday, May 27, 2009
Ultrasound Alternative To Mammograms
Radiologists can now suspend a patient's breast in water, and then send sound waves through the water in order to image breast tissue. The device uses 256 ultrasonic sensors to assemble 50 to 70 two dimensional slices into a three dimensional image of the breast that reveals cancers larger than five millimeters in diameter.
Each year more than 18-million women get a mammogram. But up to 15% of mammograms miss tell-tale signs of cancer. Now, a new technology that may be better at finding cancer and saving lives could be available.
So far it's been able to see almost all the cancers that are above five millimeters.
Developed by physicists and radiologists, the new technology, called computed ultrasound risk evaluation device -- or CURE -- does not use radiation, lasts one minute and is pain-free. While the woman's breast is suspended in water, ultrasound sensors transmit sound waves through the water. The device measures how the sound waves travel through the breast tissue. Computer images help doctors better pinpoint cancerous tissue.
"Based on the more limited trials it remains to be proven that it is more accurate than mammography.
__________________________________________________
HOW ULTRASOUND WORKS:
Ultrasound is a medical imaging technique that uses high-frequency sound waves and their echoes. It is similar to how bats navigate in the dark, and the SONAR used by submarines underwater. The machine transmits high-frequency sound pulses into the body using a probe. The sound waves travel through the body and bounce off any boundaries, such as between fluid and soft tissue, tissue and bone. Some of the sound waves are reflected back to the probe, while others travel further through until they bounce off another boundary. All the reflected waves are recorded by the machine, which then calculates the distance each sound wave traveled based on how long it took the sound wave's echo to return. This data is used to form a two-dimensional image based on the distances and intensities of those echoes.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Each year more than 18-million women get a mammogram. But up to 15% of mammograms miss tell-tale signs of cancer. Now, a new technology that may be better at finding cancer and saving lives could be available.
So far it's been able to see almost all the cancers that are above five millimeters.
Developed by physicists and radiologists, the new technology, called computed ultrasound risk evaluation device -- or CURE -- does not use radiation, lasts one minute and is pain-free. While the woman's breast is suspended in water, ultrasound sensors transmit sound waves through the water. The device measures how the sound waves travel through the breast tissue. Computer images help doctors better pinpoint cancerous tissue.
"Based on the more limited trials it remains to be proven that it is more accurate than mammography.
__________________________________________________
HOW ULTRASOUND WORKS:
Ultrasound is a medical imaging technique that uses high-frequency sound waves and their echoes. It is similar to how bats navigate in the dark, and the SONAR used by submarines underwater. The machine transmits high-frequency sound pulses into the body using a probe. The sound waves travel through the body and bounce off any boundaries, such as between fluid and soft tissue, tissue and bone. Some of the sound waves are reflected back to the probe, while others travel further through until they bounce off another boundary. All the reflected waves are recorded by the machine, which then calculates the distance each sound wave traveled based on how long it took the sound wave's echo to return. This data is used to form a two-dimensional image based on the distances and intensities of those echoes.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Thursday, May 14, 2009
Does Cancer Screening Really Help All?
No evidence so far that it helps with certain cancers reports Robert W. Rebar, MD [Journal Watch General Medicine, 2009].
As much one would like to believe that early detection for all automatically leads to better care, that is not always the case. Although it is true that finding and treating cancer at an early stage will help in some cases — such as colon cancer and Pap smears that reduce deaths from cervical cancer — the data are less conclusive for at least three other cancers.
Ovarian carcinoma
Ovarian carcinoma is the leading cause of death from gynecologic malignancies in the U.S., reports Robert W. Rebar, MD largely because diagnosis usually is not made until disease is advanced.
In a study funded by the National Cancer Institute, of more than 30,000 women in the study’s screening arm who underwent at least one annual screen, 11.1% had at least one positive test result. The positive predictive value of the tests ranged from 1.0% to 1.3% during different screening rounds, and 4.7 to 6.2 cancers per 10,000 women were identified with screening. The ratio of surgeries to detected invasive ovarian cancer cases was 19.5 to 1.
Unfortunately 72% of cancers were late stage. Because the prevalence of ovarian cancer is low, false positives are numerous and screening leads to surgery for many women who do not have cancer. The benefits of screening will outweigh the harms seems unlikely.
Prostate cancer
In an op-ed in USA Today (4/23/09), Kevin Pho, MD, a primary-care physician in New Hampshire, questions whether "early screening" is "always in the patient's best interest." Dr. Pho cited two studies appearing in the New England Journal of Medicine that examine "the effects of prostate cancer screening."
In one study, "sponsored by the National Institutes of Health," researchers "found that such screening did not decrease deaths." Meanwhile, "the second study showed that for every death prevented, 50 men would suffer from over-diagnosis." To put the problem in context: Only 3% of men die from prostate cancer; 97% will die from something else.
Almost one-third of those treated for prostate cancer suffer from significant side effects, including impotence and urinary incontinence. Taken together, the study found that the benefit was minimal, and far from definitive.
Breast Cancer[see Part II in my series of article on Mammagraphy http://drperryhookman.blogspot.com/2009/05/mammography-different-after-age-65-full.html]
Dr. K.Pho notes that "similar issues influence breast cancer screening decisions" and that physicians "cannot be sure of which cancers are dangerous." As a result, "for every life saved from breast cancer, 10 more lives will be affected by" biopsy or breast surgery. He concludes, There cannot be a one-size-fits-all approach" to preventive care.Because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.
Other cancers
The uncertainty surrounding tests is true of other cancers, including lung, skin (malignant melanoma), testicular and pancreatic (pancreatic adenocarcinoma), where little compelling evidence has shown that early screening is beneficial.
My opinion
The problem associated with these studies showing questionable or no benefit to a longer life for cancer victims is the statistics themselves. Statistics are still statistics and you are you. Some lives have been saved from early screening. But for every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.
But when only 1% of a certain population of 100 benefits that 1% may be you-and as far as you’re concerned you are 100% of the study.
Another example is that mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. Although it’s true that for every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures, yours may be the life that’s saved.
Unless you believe with Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who says, "I place considerable value on not suffering the side effects of treatment" and "death is not the only outcome that matters," you may choose not to undergo these uncertain screening procedures.
But at least you will be making an informed decision. As Dr. Pho states “patients must be better informed of the potential consequences either choice can bring.”
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
As much one would like to believe that early detection for all automatically leads to better care, that is not always the case. Although it is true that finding and treating cancer at an early stage will help in some cases — such as colon cancer and Pap smears that reduce deaths from cervical cancer — the data are less conclusive for at least three other cancers.
Ovarian carcinoma
Ovarian carcinoma is the leading cause of death from gynecologic malignancies in the U.S., reports Robert W. Rebar, MD largely because diagnosis usually is not made until disease is advanced.
In a study funded by the National Cancer Institute, of more than 30,000 women in the study’s screening arm who underwent at least one annual screen, 11.1% had at least one positive test result. The positive predictive value of the tests ranged from 1.0% to 1.3% during different screening rounds, and 4.7 to 6.2 cancers per 10,000 women were identified with screening. The ratio of surgeries to detected invasive ovarian cancer cases was 19.5 to 1.
Unfortunately 72% of cancers were late stage. Because the prevalence of ovarian cancer is low, false positives are numerous and screening leads to surgery for many women who do not have cancer. The benefits of screening will outweigh the harms seems unlikely.
Prostate cancer
In an op-ed in USA Today (4/23/09), Kevin Pho, MD, a primary-care physician in New Hampshire, questions whether "early screening" is "always in the patient's best interest." Dr. Pho cited two studies appearing in the New England Journal of Medicine that examine "the effects of prostate cancer screening."
In one study, "sponsored by the National Institutes of Health," researchers "found that such screening did not decrease deaths." Meanwhile, "the second study showed that for every death prevented, 50 men would suffer from over-diagnosis." To put the problem in context: Only 3% of men die from prostate cancer; 97% will die from something else.
Almost one-third of those treated for prostate cancer suffer from significant side effects, including impotence and urinary incontinence. Taken together, the study found that the benefit was minimal, and far from definitive.
Breast Cancer[see Part II in my series of article on Mammagraphy http://drperryhookman.blogspot.com/2009/05/mammography-different-after-age-65-full.html]
Dr. K.Pho notes that "similar issues influence breast cancer screening decisions" and that physicians "cannot be sure of which cancers are dangerous." As a result, "for every life saved from breast cancer, 10 more lives will be affected by" biopsy or breast surgery. He concludes, There cannot be a one-size-fits-all approach" to preventive care.Because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.
Other cancers
The uncertainty surrounding tests is true of other cancers, including lung, skin (malignant melanoma), testicular and pancreatic (pancreatic adenocarcinoma), where little compelling evidence has shown that early screening is beneficial.
My opinion
The problem associated with these studies showing questionable or no benefit to a longer life for cancer victims is the statistics themselves. Statistics are still statistics and you are you. Some lives have been saved from early screening. But for every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.
But when only 1% of a certain population of 100 benefits that 1% may be you-and as far as you’re concerned you are 100% of the study.
Another example is that mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. Although it’s true that for every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures, yours may be the life that’s saved.
Unless you believe with Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who says, "I place considerable value on not suffering the side effects of treatment" and "death is not the only outcome that matters," you may choose not to undergo these uncertain screening procedures.
But at least you will be making an informed decision. As Dr. Pho states “patients must be better informed of the potential consequences either choice can bring.”
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Sunday, May 3, 2009
MAMMOGRAPHY-DIFFERENT AFTER AGE 65? – FULL DISCLOSURE: PART II of II
Many of my GI patients and friends retired to South Florida have asked me to research the use of Mammography in women past the age of 65 so they can make informed decisions with their personal and family doctors.
First we should realize that more than half of the cases of breast cancer treated in the United States occur in women over age 65. Yet mammography screening for older women is controversial, because no good randomized trials [prospective evaluation of a control vs. an experimental population] of such screening have been conducted in older populations.
This is what I researched for them.
Bottom Line: Effectiveness was modest and false positives were common. But there are pros and cons which I present here to augment full and informed decisions with their personal physicians.
CONS:
In the one prospective cohort study from three outpatient clinics in Boston, [Published in Journal Watch General Medicine April 30, 2009[Schonberg MA et al. Weighing the benefits and burdens of mammography screening among women age 80 years or older also J Clin Oncol 2009 Apr 10; 27:1774], researchers tracked mammography screening and breast cancer outcomes in over 2000 women (age, 80 at the beginning of the observation period) and who were followed for 2 to 12 years (median, 5 years).
Half the women underwent mammography (average, about 2.5 mammograms per screened patient), and half did not. Twenty-eight breast cancers (including 8 ductal carcinomas in situ) were diagnosed among mammography recipients, and 20 were diagnosed among women who did not undergo mammography (half by clinician exam and half by patient-reported symptoms or signs).
Breast cancer that was diagnosed during the study interval caused one death in the mammography group and two deaths in the no-mammography group.
According to the J Clin Oncol. 2009 Apr 10;27(11):1774-80. Epub 2009 Mar 2, among screened women, 11% have false-positive mammograms that results in additional imaging tests or biopsies. Conclusions reached by the authors are that the majority of women > or = 80 years are screened with mammography yet few benefit.
Meanwhile, 12.5% experience a burden [extra tests, some invasive] from screening.
Because this study was small and because these women were not randomized, it cannot serve as a general rule of mammographic screening in the older woman. But it does suggest that the effectiveness of mammography is modest at best among women in their 80s and that the false-positive rate is not trivial in this age group. False positives you know lead to more aggressive and sometimes dangerous follow-up tests.
How about the issue of Mammography in older frail women?
Walter and Covinsky [J Gen Intern Med. 2001 Nov;16(11):779-84.] concludes that screening mammography in frail older women frequently necessitates work-up that does not result in benefit. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.
PRO Mammography in the Older Woman
McCarthy EP, et al. from Harvard [J Am Geriatr Soc. 2000 Oct;48(10):1226-33.Mammography use, breast cancer stage at diagnosis, and survival among older women. ] showed that women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Older women the authors say who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. Their data support the use of regular mammography in older women at least those age 65 and suggest that mammography can even reduce breast cancer mortality in older women, even for women age 85 and older.
[Cancer. 1996 Dec 15;78(12):2526-34.The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.] Roetzheim R, et al selected women to undergo mammography based on risk factors in women age 65 years or older). These risk factors included women with a family history of breast carcinoma and women who have had incidental radiation exposure of breast tissue which significantly increases the risk of breast cancer. The authors concluded that older women with additional risk factors should more likely to undergo screening mammography and that interventions that target older women with risk factors and their physicians thus appear warranted.
[J Clin Oncol. 2007 Jul 20;25(21):3001-6. Epub 2007 Jun 4. Mammography surveillance and mortality in older breast cancer survivors.] Lash TL et al. performed a large observational study which provides support for mammography in older women aged 65 and older and appears reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.
[Breast Cancer Res Treat. 2008 Oct;111(3):489-96. Epub 2007 Oct 24.Surveillance mammography and the risk of death among elderly breast cancer patients.]
Schootman M et al examined the benefits of mammography for elderly breast cancer survivors in community settings. He found that among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period. Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals. They concluded that in community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.
My opinion about mammography in the older woman?
Finally we should know this. There are attitudinal differences by medical providers in the diagnosis and treatment of breast cancer in women over 65.
A retrospective review of all women with primary operable invasive breast cancer treated at the University of Michigan Breast Care Center over a 30-month period was reviewed in the [Ann Surg Oncol. 1994 Jan;1(1):45-52. Age-related differences in breast cancer treatment.August DA et al.from the Department of Surgery, University of Michigan, Ann Arbor 48109-0331.]
This was a study of a total of 77 older patients aged > or = 65 years (median, 71; oldest patient, 92). Fifty-one similar younger patients aged 55-64 years (median, 59) were identified for comparison.
Patients were classified as either having received standard treatment or non-standard treatment. When overall treatment (local/regional plus systemic) was assessed, proportionately fewer older patients received standard treatment. Overall, only 59 of 77 older patients versus 50 of 51 younger patients received standard local/regional care.
Older patients were less likely to receive chemotherapy than younger patients (7% versus 50%; p < 0.001). “Interestingly,” say the authors, “explanations for decisions to deviate from standard treatment guidelines were often not identified.”
These data demonstrate age-related variations in breast cancer treatment in a multidisciplinary breast care unit. Although good clinical judgment may have played a role in these differences, via age-related patient preferences and co-morbidity, “the age-related attitudes of caregivers must also be taken into account to fully explain these variations,” state the authors.
In conclusion, after I go through a full discussion with patients listing all the pros and cons I’m then almost always asked this question? Dr. Hookman-That’s all well and good-but what would you suggest if I was your sister?
My answer is always that each case has to be individualized to your medical history, your risk factors, you physical exam, you routine lab data-even your anxiety level etc.
But all the above factors being considered and evaluated I would go ahead and recommend annual to biannual mammograms in patients over 65-especially with increased risk factors enumerated above, and be wary of any attitudinal difference in medical provider behavior towards older patients.
Please remember, however, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s].
These articles are not to be taken as medical advice for you.
First we should realize that more than half of the cases of breast cancer treated in the United States occur in women over age 65. Yet mammography screening for older women is controversial, because no good randomized trials [prospective evaluation of a control vs. an experimental population] of such screening have been conducted in older populations.
This is what I researched for them.
Bottom Line: Effectiveness was modest and false positives were common. But there are pros and cons which I present here to augment full and informed decisions with their personal physicians.
CONS:
In the one prospective cohort study from three outpatient clinics in Boston, [Published in Journal Watch General Medicine April 30, 2009[Schonberg MA et al. Weighing the benefits and burdens of mammography screening among women age 80 years or older also J Clin Oncol 2009 Apr 10; 27:1774], researchers tracked mammography screening and breast cancer outcomes in over 2000 women (age, 80 at the beginning of the observation period) and who were followed for 2 to 12 years (median, 5 years).
Half the women underwent mammography (average, about 2.5 mammograms per screened patient), and half did not. Twenty-eight breast cancers (including 8 ductal carcinomas in situ) were diagnosed among mammography recipients, and 20 were diagnosed among women who did not undergo mammography (half by clinician exam and half by patient-reported symptoms or signs).
Breast cancer that was diagnosed during the study interval caused one death in the mammography group and two deaths in the no-mammography group.
According to the J Clin Oncol. 2009 Apr 10;27(11):1774-80. Epub 2009 Mar 2, among screened women, 11% have false-positive mammograms that results in additional imaging tests or biopsies. Conclusions reached by the authors are that the majority of women > or = 80 years are screened with mammography yet few benefit.
Meanwhile, 12.5% experience a burden [extra tests, some invasive] from screening.
Because this study was small and because these women were not randomized, it cannot serve as a general rule of mammographic screening in the older woman. But it does suggest that the effectiveness of mammography is modest at best among women in their 80s and that the false-positive rate is not trivial in this age group. False positives you know lead to more aggressive and sometimes dangerous follow-up tests.
How about the issue of Mammography in older frail women?
Walter and Covinsky [J Gen Intern Med. 2001 Nov;16(11):779-84.] concludes that screening mammography in frail older women frequently necessitates work-up that does not result in benefit. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.
PRO Mammography in the Older Woman
McCarthy EP, et al. from Harvard [J Am Geriatr Soc. 2000 Oct;48(10):1226-33.Mammography use, breast cancer stage at diagnosis, and survival among older women. ] showed that women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Older women the authors say who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. Their data support the use of regular mammography in older women at least those age 65 and suggest that mammography can even reduce breast cancer mortality in older women, even for women age 85 and older.
[Cancer. 1996 Dec 15;78(12):2526-34.The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.] Roetzheim R, et al selected women to undergo mammography based on risk factors in women age 65 years or older). These risk factors included women with a family history of breast carcinoma and women who have had incidental radiation exposure of breast tissue which significantly increases the risk of breast cancer. The authors concluded that older women with additional risk factors should more likely to undergo screening mammography and that interventions that target older women with risk factors and their physicians thus appear warranted.
[J Clin Oncol. 2007 Jul 20;25(21):3001-6. Epub 2007 Jun 4. Mammography surveillance and mortality in older breast cancer survivors.] Lash TL et al. performed a large observational study which provides support for mammography in older women aged 65 and older and appears reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.
[Breast Cancer Res Treat. 2008 Oct;111(3):489-96. Epub 2007 Oct 24.Surveillance mammography and the risk of death among elderly breast cancer patients.]
Schootman M et al examined the benefits of mammography for elderly breast cancer survivors in community settings. He found that among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period. Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals. They concluded that in community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.
My opinion about mammography in the older woman?
Finally we should know this. There are attitudinal differences by medical providers in the diagnosis and treatment of breast cancer in women over 65.
A retrospective review of all women with primary operable invasive breast cancer treated at the University of Michigan Breast Care Center over a 30-month period was reviewed in the [Ann Surg Oncol. 1994 Jan;1(1):45-52. Age-related differences in breast cancer treatment.August DA et al.from the Department of Surgery, University of Michigan, Ann Arbor 48109-0331.]
This was a study of a total of 77 older patients aged > or = 65 years (median, 71; oldest patient, 92). Fifty-one similar younger patients aged 55-64 years (median, 59) were identified for comparison.
Patients were classified as either having received standard treatment or non-standard treatment. When overall treatment (local/regional plus systemic) was assessed, proportionately fewer older patients received standard treatment. Overall, only 59 of 77 older patients versus 50 of 51 younger patients received standard local/regional care.
Older patients were less likely to receive chemotherapy than younger patients (7% versus 50%; p < 0.001). “Interestingly,” say the authors, “explanations for decisions to deviate from standard treatment guidelines were often not identified.”
These data demonstrate age-related variations in breast cancer treatment in a multidisciplinary breast care unit. Although good clinical judgment may have played a role in these differences, via age-related patient preferences and co-morbidity, “the age-related attitudes of caregivers must also be taken into account to fully explain these variations,” state the authors.
In conclusion, after I go through a full discussion with patients listing all the pros and cons I’m then almost always asked this question? Dr. Hookman-That’s all well and good-but what would you suggest if I was your sister?
My answer is always that each case has to be individualized to your medical history, your risk factors, you physical exam, you routine lab data-even your anxiety level etc.
But all the above factors being considered and evaluated I would go ahead and recommend annual to biannual mammograms in patients over 65-especially with increased risk factors enumerated above, and be wary of any attitudinal difference in medical provider behavior towards older patients.
Please remember, however, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s].
These articles are not to be taken as medical advice for you.
Saturday, May 2, 2009
MAMMOGRAPHY – FULL DISCLOSURE: PART I OF II
Leonard Berlin, MD, FACR, is chairman, of the Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, and professor of radiology, Rush Medical College, Chicago. He writes that misinformation of mammography is the cause of much confusion and medical malpractice suits. He has strongly held opinions- expressed in a pointed way. For instance-
• “The allegation of a delay in the diagnosis of breast cancer is the leading cause of medical malpractice litigation in the United States today, and has been for the past decade.
• Of all medical malpractice lawsuits filed in the United States that allege a delay in the diagnosis of breast cancer, radiologists are the most frequently sued specialists.
• Of all medical malpractice lawsuits lodged against radiologists, the most frequent cause is the allegation of a missed breast cancer on mammography. Why has "missed breast cancer" risen to first place in the medical malpractice standings?
• Berlin suggests that it is because we have oversold mammography. We have marketed mammography without informing the American public all that we know about not only the benefits, but also more important the limitations and potential harms of mammography. True, admits Berlin, the high level of mammographic utilization that we have achieved through these marketing efforts has resulted in overall improvement in the health and welfare of American women, but at the same time, this marketing has resulted in something that can be considered detrimental: an exponential growth in malpractice litigation alleging misinterpretation of mammograms.
We opines Berlin- that is, the radiology community know that there are divergent opinions in the scientific community. There are contradictory interpretations of available data that deal with the question of whether early diagnosis of breast cancer by means of mammography, and whether it does, or does not, lower the mortality rate from breast cancer. We know that while there has been a decrease in the number of deaths attributable to breast cancer, it is not clear whether it has resulted from earlier diagnosis or better treatment, or both. His strongly presented viewpoints are as follows:
• In as many as 70% of patients in which a new mammogram discloses a cancer, a finding that probably represented the cancer is visible, in retrospect, on a preceding mammogram that had been interpreted as normal.
• We know that some breast cancers are so virulent and possess such high-grade malignant potential that even if they are detected early by mammography, it will be too late to prevent a woman from dying of the disease.
• We know that some breast cancers grow so slowly and possess such low-grade malignant potential that the value of early diagnosis is questionable and in such cases, delays in diagnosis will not adversely affect the patient's chance for cure.
• We know that the percentage of ductal carcinoma in situ (DCIS) cases that will evolve into invasive carcinoma lies between 14% and 60%,
• and that the death rate within 10 years among patients with DCIS is 1% to 2%.
Finally Berlin points to the tenets of preventive medicine which promises a lot and especially to an article entitled "The Arrogance of Preventive Medicine in which a Canadian internist-researcher identified three elements of arrogance that he believes characterize the field of preventive medicine:
• First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy.
• Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them.
• Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.
Berlin opines based on this article that-
• Many radiologists believe so strongly that every woman will benefit from mammography that they fear that merely discussing potential negatives regarding mammography will dissuade women from undergoing the examination.
• During busy office visits, it is difficult to thoroughly discuss with women the benefits and harms of mammography...Nevertheless; we should strive to correct misperceptions whenever possible.
• Many women overestimate the protective benefits of mammography and underestimate its possible risks, including the evaluation of false-positive mammograms and over diagnosis leading to unnecessary mastectomy, radiation, or chemotherapy.
• Clinicians should describe potential benefits of mammography without candy coating its plausible harms.
Internist-author H. Gilbert Welch has commented as follows:
Ideally, the "right" reason [for women to undergo mammography] would be that each woman had made an informed choice, or in other words, had made her own decision after being fully informed of the likely benefits and harms of screening experienced by women just like her. While such ideal conditions for decision making may exist somewhere, I don't foresee them on our planet any time soon...Perhaps if we used less alarming language about cancer risk when we introduce patients to screening, they would have less need for reassurance...We [should talk about screening] in the context of choice instead of obligation.
For that reason and for fully informed decision making by women I will be posting Article II in this duo of mammography research tomorrow.
• “The allegation of a delay in the diagnosis of breast cancer is the leading cause of medical malpractice litigation in the United States today, and has been for the past decade.
• Of all medical malpractice lawsuits filed in the United States that allege a delay in the diagnosis of breast cancer, radiologists are the most frequently sued specialists.
• Of all medical malpractice lawsuits lodged against radiologists, the most frequent cause is the allegation of a missed breast cancer on mammography. Why has "missed breast cancer" risen to first place in the medical malpractice standings?
• Berlin suggests that it is because we have oversold mammography. We have marketed mammography without informing the American public all that we know about not only the benefits, but also more important the limitations and potential harms of mammography. True, admits Berlin, the high level of mammographic utilization that we have achieved through these marketing efforts has resulted in overall improvement in the health and welfare of American women, but at the same time, this marketing has resulted in something that can be considered detrimental: an exponential growth in malpractice litigation alleging misinterpretation of mammograms.
We opines Berlin- that is, the radiology community know that there are divergent opinions in the scientific community. There are contradictory interpretations of available data that deal with the question of whether early diagnosis of breast cancer by means of mammography, and whether it does, or does not, lower the mortality rate from breast cancer. We know that while there has been a decrease in the number of deaths attributable to breast cancer, it is not clear whether it has resulted from earlier diagnosis or better treatment, or both. His strongly presented viewpoints are as follows:
• In as many as 70% of patients in which a new mammogram discloses a cancer, a finding that probably represented the cancer is visible, in retrospect, on a preceding mammogram that had been interpreted as normal.
• We know that some breast cancers are so virulent and possess such high-grade malignant potential that even if they are detected early by mammography, it will be too late to prevent a woman from dying of the disease.
• We know that some breast cancers grow so slowly and possess such low-grade malignant potential that the value of early diagnosis is questionable and in such cases, delays in diagnosis will not adversely affect the patient's chance for cure.
• We know that the percentage of ductal carcinoma in situ (DCIS) cases that will evolve into invasive carcinoma lies between 14% and 60%,
• and that the death rate within 10 years among patients with DCIS is 1% to 2%.
Finally Berlin points to the tenets of preventive medicine which promises a lot and especially to an article entitled "The Arrogance of Preventive Medicine in which a Canadian internist-researcher identified three elements of arrogance that he believes characterize the field of preventive medicine:
• First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy.
• Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them.
• Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.
Berlin opines based on this article that-
• Many radiologists believe so strongly that every woman will benefit from mammography that they fear that merely discussing potential negatives regarding mammography will dissuade women from undergoing the examination.
• During busy office visits, it is difficult to thoroughly discuss with women the benefits and harms of mammography...Nevertheless; we should strive to correct misperceptions whenever possible.
• Many women overestimate the protective benefits of mammography and underestimate its possible risks, including the evaluation of false-positive mammograms and over diagnosis leading to unnecessary mastectomy, radiation, or chemotherapy.
• Clinicians should describe potential benefits of mammography without candy coating its plausible harms.
Internist-author H. Gilbert Welch has commented as follows:
Ideally, the "right" reason [for women to undergo mammography] would be that each woman had made an informed choice, or in other words, had made her own decision after being fully informed of the likely benefits and harms of screening experienced by women just like her. While such ideal conditions for decision making may exist somewhere, I don't foresee them on our planet any time soon...Perhaps if we used less alarming language about cancer risk when we introduce patients to screening, they would have less need for reassurance...We [should talk about screening] in the context of choice instead of obligation.
For that reason and for fully informed decision making by women I will be posting Article II in this duo of mammography research tomorrow.
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